Specialist training of family physicians in non-UEMO countries: An Estonian experience

ABSTRACT

Background: Because of the growth of the older population and the prevalence of chronic diseases, home care services (HCS) have become an important aspect of healthcare worldwide. However, various difficulties and deficiencies are present in the provision of these recently implemented services in Turkey. Modifications to home healthcare services are in progress.

Objective: Physicians have an active role in home healthcare services. The present study was performed to examine physicians’ attitudes toward this service in detail.

Methods: Twenty-six physicians who provide home healthcare services in the city of Ankara were included in the study. We conducted in-depth, semi-structured, face-to-face interviews. The interviews were audio-recorded, transcribed, and qualitatively analysed.

Results: Most physicians thought that home care could be provided to patients who are bedridden, are very old, have a chronic disease, have problems leaving the house, or do not have family support. They also expressed displeasure about the abuse of services and discordance of organization between hospitals and primary care centres. They noted that real circumstances in practice were not compatible with regulations and that cooperation and coordination between departments are necessary and important.

Conclusion: The current study underlines physicians’ interest in and support of the home care system, which has various drawbacks and limitations. Legislation needs to be further changed to improve the quality of service and eliminate deficiencies in home healthcare.     

北京市西城区居民对家庭医生式服务的需求情况调查

目的 了解北京市西城区居民对家庭医生式服务的需求现状,为家庭医生式服务的深入推进提供参考.方法 采用自行设计的调查问卷,采取整群随机抽样的方法对西城区2 861名居民进行调查.结果 服务需求排在前5位的依次是中医药服务,健康咨询,及时得到医疗服务,慢病管理和康复训练,对空巢、行动不便的老人提供上门服务.老年人群和慢性病人群的前5位需求与全体调查人群基本一致.82.4%的居民赞同患病后首先由全科医生进行诊治,94.9%的居民愿意继续与全科医生团队保持签约关系.结论 社区居民对家庭医生式服务接受度高,服务需求存在差异.建议遵循按需服务的工作原则,推出更满足居民需求的签约服务内容.同时继续加强全科医学人才队伍建设,逐步开展社区首诊的实践.     

Too many and too few: The paradoxical case of physicians in the Russian Federation

There is a paradox characterising the Russian health workforce. By international standards, Russia has a very high number of physicians per capita but at the same time is confronted by chronic real shortages of qualified physicians. This paper explores the reasons for this paradox by examining the structural characteristics of health workforce development in the context of the Soviet legacy and the comparative performance of other European countries. The paper uses data on comparative health workforce dynamics to argue that Russia is a European laggard, before then evaluating recent and current policies within that context. The health workforce challenges facing all low‐ and middle‐income countries are acute, and this paper confirms this IS the case for Russia—Europe's largest country. The paper argues that the physician shortage is driven by the model of health workforce development inherited from the Soviet period, with its emphasis on quantitative rather than structural indicators. We find that, in contrast to most European Union countries, Russia's stalled reform process leaves it facing a chronic shortage of appropriately trained physicians. We document the costs of failed and slow reforms during the last 2 decades, while cautiously welcoming some recent policy initiatives.     

Educating Future Physicians in Nutritional Science and Practice: The Time Is Now

The need to educate and train future physicians about nutrition and wellness has become increasingly apparent in the past decade. A rising incidence of chronic health conditions with a nutrition background (e.g., obesity, cardiovascular disease, type 2 diabetes) has led to an even greater need for nutrition educational content in medical school curricula so that physicians may counsel patients regarding their lifestyle factors. This review provides an overview of the successful development and integration of a nutrition thread in a 5-year medical school curriculum. Based on a survey conducted in our medical school program, students beginning medical school are lacking formal nutrition education, as only 8% arrived with some form of exposure. Despite this, nearly 85% of these medical students recognized that nutrition education is necessary in their training, and 70% state that the nutrition education they have received has influenced the way they care for patients.

• Key teaching points

• Physicians are faced with rising incidence of chronic health conditions that have a nutritional risk factor

• Physician self-care including optimal nutrition to support resilience is gaining importance.

• Nutrition education in medical schools is inadequate to address these rising needs.

• Implementing a comprehensive nutrition curricula that addresses personal wellness strategies, basic science concepts related to nutrition, and diagnosis and management of diseases that can be modified by or are related to nutrition as a topic thread that is woven throughout all years of the curriculum highlights the importance of nutrition in health and disease.

     

北京地区非呼吸科医生对慢性阻塞性肺疾病管理认知度的调查

目的 针对北京地区非呼吸科医生对慢性阻塞性肺疾病（COPD）的理论知识、诊疗习惯和健康管理进行调查,为疾病的预防和综合干预提供依据.方法 选取2012年1月至2013年1月北京市5个区县9所不同级别医院的共计370名非呼吸科内科医生作为调查对象发放调查问卷.以问卷的正确率作为认知程度的评价依据.采用卡方检验和方差分析进行统计分析.结果 一级医院与二、三级医院相比,非呼吸科医生对COPD的整体认知程度明显较差（正确率分别为57.5±17.1,67.1±15.0,68.9±13.6,F=18.75,P＜0.05）.住院医师和主治医师的认知程度明显低于（副）主任医师（正确率分别为61.4±12.9,61.4± 15.0,79.3± 13.2,F=34.82,P＜0.05）.结论 北京地区的非呼吸科医生对COPD的整体认知程度不高.建议加强对非呼吸科的医生、基层医院的医生,特别是年轻医生的COPD理论和诊治规范的培训.     

Does trust of patients in their physician predict loyalty to the health care insurer? The Israeli case study

ABSTRACT

This pioneer study tests the relationship between patients’ trust in their physicians and patients’ loyalty to their health care insurers. This is a cross-sectional study using a representative sample of patients from all health care insurers with identical health care plans. Regression analyses and Baron and Kenny’s model were used to test the study model. Patient trust in the physician did not predict loyalty to the insurer. Loyalty to the physician did not mediate the relationship between trust in the physician and loyalty to the insurer. Satisfaction with the physician was the only predictor of loyalty to the insurer.     

Australian health policy and end of life care for people with chronic disease: An analysis

End of life care for people with advanced chronic disease is a growing international imperative, with the majority of deaths in the world now related to chronic disease. The provision of care that meets the needs of people with advanced chronic disease must be guided by appropriate policy. The key policy areas impacting directly on end of life care are related to chronic disease, palliative care and, increasingly, aged care.     

Disciplinary careers of drug-impaired physicians

Alcohol and drug abuse are among the leading reasons for disciplinary action against physicians by state licensing authorities in the United States. I use event history models to describe the longitudinal patterns in disciplinary actions taken against physicians' licenses by state medical boards in the United States, 1990-2000. Adverse licensure action episodes that included discipline for drug or alcohol abuse were more likely to be followed by license restoration than episodes that did not. However, those restorations were also more likely to be followed by subsequent disciplinary action than episodes that did not include discipline for drug abuse. Furthermore, disciplinary licensure actions for drug abuse were the category most likely to be followed by a subsequent action for the same reason over the longer term (4-11 years). The increased risk of repeat disciplinary action associated with drug abuse may result in part from intensive surveillance of physicians who complete impaired physician programs, through mechanisms that include urine screening. However, it is also likely that the chronic nature of addiction leads to continued risk of relapse even among physicians receiving appropriate treatment.     

Factors affecting uptake of influenza vaccination among family physicians

AimThe aim of this study was to determine the factors that influenced the decisions of family physicians working in primary care health services to receive influenza vaccines.MethodsThis cross-sectional study was performed between June 2014 and September 2014. Physicians were reached electronically via e-mail. A self-reported questionnaire consisting of 50 items covering potential factors that may have influenced their decision to receive vaccination, including perceived risk, severity of the perceived risk, perceived benefit, perceived barriers, cues to action, attitudes, social influences and personal efficacy, was administered to the study participants. Cronbach's alpha for the questionnaire was determined to be 0.92 in the pilot study.ResultsThe response rate was 27.5% (n = 596). Regularly vaccinated physicians accounted for 27.3% of the responses. The median age was 41.84 ± 7.80, and the median working duration of the group was 17.0 ± 7.8 years. The factors that led to increased vaccination compliance (p < 0.05) included working duration, age, chronic disease history and living with a person over 65 years. Nearly all major domains, i.e., perceived risk, severity of the perceived risk, perceived benefit, perceived barriers, attitudes, social influences and personal efficacy, there were differences between the compliant and noncompliant groups. Multi-regression analyses revealed that risk perception, organizational factors such as time and convenient vaccination increased vaccine compliance. However, the perceived necessity to be vaccinated annually had a negative effect on vaccination behaviour (p < 0.05).ConclusionStrategies aimed to increase the flu vaccination ratio among physicians that do not take different factors into account are more likely to be unsuccessful. In the planning and implementation of strategies aiming to increase the vaccination ratio among physicians, it is both necessary and important to take into account behavioural and organizational factors.     

The professional self-evaluation of immigrant physicians from the former Soviet Union in Israel

This study tests the hypothesis that the personal construction of a positive professional identity is central to immigrant physicians' psychosocial well-being. Data are derived from responses to structured questionnaires from the first and third stages of a 5-year, three-stage cohort study of physicians who immigrated to Israel from the former Soviet Union in 1990. At the third stage of the study, in 1995, 387 physicians were working as physicians of a total of 519 respondents. Previous analyses of this research population showed that the immigrants who obtained work in their profession had significantly higher scores on a variety of indicators of psychosocial well-being than those who did not. In this paper, which narrows its focus to those who were working as physicians in 1995, significant positive relationships were found among three measures of self-evaluation, and between professional self-esteem, global self-esteem, and work satisfaction, and adaptation to life in Israel. General practitioners and specialists scored higher on professional self-evaluation than residents. Women scored higher than men, and older respondents (age's 36–45) scored higher than younger respondents (ages 25–35). The immigrant physicians viewed themselves as similar to their Israeli-trained colleagues in terms of their professional role behavior and were particularly positive about their diagnostic skills and the quality of their relationships with their patients. These findings are discussed in terms of role theory, which suggests that the work role of professionals is the most salient component of their self-identify.     

Selecting performance assessment methods for experienced physicians

BACKGROUND: While much is now known about how to assess the competence of medical practitioners in a controlled environment, less is known about how to measure the performance in practice of experienced doctors working in their own environments. The performance of doctors depends increasingly on how well they function in teams and how well the health care system around them functions. METHODS: This paper reflects the combined experiences of a group of experienced education researchers and the results of literature searches on performance assessment methods. CONCLUSION: Measurement of competence is different to measurement of performance. Components of performance could be re-conceptualised within a different domain structure. Assessment methods may be of a different utility to that in competence assessment and, indeed, of different utility according to the purpose of the assessment. An exploration of the utility of potential performance assessment methods suggests significant gaps that indicate priority areas for research and development.     

New thinking and science on disability in mid- and late life

Disability refers to the impacts that chronic conditions haveon people's ability to act in necessary, expected and personallydesired ways in their society. Scientists are now working totrace trajectories of disability over time for individuals andidentify factors that propel and slow disability's pace. Theirwork is guided by conceptual schemes that Include i) a mainpathway linking pathology, impairments, functional limitations,disability, and social disadvantage and ii) predisposing riskfactors, interventions and exacerbators that alter the paceof that pathway. Recent findings from 3 projects are presentedon the disabling impact of various chronic conditions, dynamicsof disability for individuals and successful interventions.The results show the importance of non-fatal conditions as causesof disability in late life, how chronic conditions Increasetime spent by older persons on obligatory activities while reducingtime spent on discretionary ones and the great efficacy of personaland (especially) equipment assistance in reducing disability.We discuss medicine's dreams of primary prevention, contrastedwith the actual advances in secondary prevention in the pasthalf century and how those advances now prompt needs for preventionstrategies that maintain and restore function among personswith chronic conditions.     

The Effect of Capitation on Switching Primary Care Physicians

Objective.  To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs.
Data Sources/Study Setting.  Administrative enrollment and claims/encounter data for 1994–1995 from four physician organizations.
Study Design.  We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods.
Data Collection/Extraction Methods.  Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis.
Principal Findings.  Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs.
Conclusions.  A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.     

Twenty-five years of the international Bled course for teachers of family medicine in Europe: Glancing back and looking forward

The international Bled course for teacher training has played a central role in faculty development in family medicine for the past 25 years. The course was originally designed to promote faculty development for family medicine teachers in the new academic discipline of family medicine in Slovenia in 1990 and to introduce new topics into the family medicine curriculum. In this background paper, we perform a SCOT analysis (strengths, challenges, opportunities, and threats) of the current course, evaluating participant feedback and reviewing past topics and their impact on local and international teaching programmes. We also review the place of the course in the context of other teacher-training programmes in family medicine in Europe. We found that the structure and learning aims of the Bled course have remained stable over 25 years. It provides a safe, well-structured learning environment for the participants even though the course topic is different every year. The course has had a significant impact on curriculum development and teacher training in Slovenia as well as in many other countries in Europe and beyond. Because of the positive impact of the course and the high degree of satisfaction of the participants and course directors, it seems worthwhile to continue this endeavour. New directions for the course will depend on the learning needs of the participants and the evolving medical curricula in the countries they represent.     

Paediatric training for family doctors: principals and practice

BACKGROUND: There is controversy as to how best to train general practitioners for the paediatric challenges they will meet in practice, in particular what should be included in training, what should be left out and how long should it last? SUBJECTS AND METHODS: All 615 general practice principals referring to 6 hospitals were surveyed (40% response rate). SETTING: West Midlands region of England. STUDY DESIGN: Postal questionnaire. STATISTICS: Quantitative and qualitative assessment of responses. Quantitative responses were analysed by hospital, decade of qualification, and duration of paediatric training. Qualitative responses were analysed using grounded theory. RESULTS: Satisfaction with training was directly related to its duration, with low levels of satisfaction for less than 6 months paediatrics, moderate levels for 6-11 months, and high levels with 12 months or more. The most important item of training was recognition of the sick child. Acute and chronic paediatrics was generally well covered. Psychosocial aspects, public health and immunisation were poorly addressed. Neonatal resuscitation and first day checks were seen as relevant, but neonatal intensive care was not. CONCLUSIONS: At least 6 months of paediatrics is necessary for GPs in training, but longer paediatric exposure further increases their satisfaction with training. GPs have a biopsychosocial rather than biomedical approach to their child patients, suggesting potential benefits from a greater emphasis on psychosocial and public health aspects at the expense of neonatal intensive care. Recognition of the sick child is essential, and acute and chronic organic illness should be covered in breadth. Possible future models for GP training in paediatrics are discussed.     

Treatment of Wilson's disease with zinc: XI. Interaction with other anticopper agents.

Zinc (Zn) is increasingly being used as a treatment for Wilson's disease. Some physicians have been prescribing Zn in conjunction with other anticopper agents, such as penicillamine or trien, although theoretically these drugs might be antagonistic in their effects. In addition, Wilson's disease patients quite often take vitamin C in high doses in conjunction with Zn therapy, and there are indications of possible interactions among vitamin C, Zn and copper (Cu). Interactions of penicillamine, trien, and vitamin C with Zn have not been previously studied in terms of the potential effects of these agents on Zn efficacy in Wilson's disease. Here we have studied these interactions in the maintenance phase of therapy, using Cu balance and absorption of orally administered 64Cu as endpoints. We find evidence for probable interactions of both penicillamine and trien with Zn; however, the end result on Cu balance is about the same with Zn alone as it is with Zn plus one of the other agents. Thus, there appear to be no advantages to concomitant administration. We find no detectable interaction of Zn and vitamin C on Cu balance, when vitamin C is taken in daily doses of 1000 mg.     

The prevalence of chronic diseases and major disease risk factors at different ages among 150 000 men and women living in Mexico City: cross-sectional analyses of a prospective study

Background  

While most of the global burden from chronic diseases, and especially vascular diseases, is now borne by low and middle-income countries, few large-scale epidemiological studies of chronic diseases in such countries have been performed.     

Long-acting beta 2-agonists in chronic obstructive pulmonary disease

Until recently, the use of long-acting beta 2-agonists in chronic obstructive pulmonary disease has been understated. There is now evidence that they may offer benefits beyond bronchodilation. This article reviews the management of chronic obstructive pulmonary disease and looks at the place of long-acting beta 2-agonists as a first-line treatment option.     

Students with chronic diseases: nature of school physician support

Background: To educate children with chronic diseases in the least restrictive environment, schools must prevent, recognize, and react appropriately to symptom exacerbations. Schools are often pushed to their limits of knowledge, resources, and comfort level. This study determined the health conditions of students for whom districts seek school physician consultation and the nature of school physician consultants’ involvement. Methods: A retrospective record review was performed on 250 of the most recent records of school‐elicited referrals from an academic center that provides physician consultation to school districts. Referrals were sent from 8 school districts in southern California (July 1996 to October 2006). Data collected were nature of student’s special health need, the school physician consultant’s intervention required to satisfy schools’ needs, student grade level, enrollment in special education, and health‐related excessive absenteeism. Results: No single chronic condition, symptom, or special health care need predominated. Six types of school physician consultant activities were used to overcome hurdles schools faced when accommodating students with special health care needs. The 3 most common were direct communication with students’ own physicians (70% of students), recommending an appropriate level of school health services when this was a matter of controversy (42%), and formulating portions of students’ individualized school health plans (38%). Conclusions: A portion of students with special health care needs benefited from district referral to a school physician consultant. Whether some of these referrals can be avoided if school personnel and students’ own physicians are supported and trained to communicate more effectively with one another needs to be explored.